Depression, anxiety, and stress among urban and rural adolescents in Shivamogga, Karnataka

Background Currently there are 1.3 billion adolescents worldwide, which makes up 16% of the world population. Over 20% of adolescents around the world are thought to have behavioural or mental health issues. Addressing mental health issues is very important for the promotion of positive health in adolescents. This study aimed to estimate the prevalence of depression, anxiety and stress among adolescents in urban and rural areas of Shivamogga. Methods A cross-sectional study was conducted among 350 adolescents aged 16 to 19 years each from urban and rural areas of Shivamogga. Results Depression, anxiety and stress were found to be 23.1%, 29.4% and 26.6% in urban areas and 19.1%, 24% and 21.1% in rural areas respectively. Depression was more common among females in both urban and rural settings, with a significant difference observed in rural areas. Anxiety and stress were also more prevalent among females, with anxiety significantly higher in urban females. Urban adolescents exhibited higher levels of depression, anxiety, and stress compared to their rural counterparts. Conclusions About a quarter of the adolescent population suffers from depression anxiety and stress. Adopting and implementing better education and health policies are necessary to enhance adolescent mental health.


Introduction
Currently, there are 1.3 billion adolescents worldwide, constituting 16% of the global population. 1 In regions like the South-East Asia region (SEAR) of the World Health Organization (WHO) and India, adolescents represent an even larger proportion, with percentages reaching 20% and 21.8% respectively. 2,3This significant demographic is facing a critical challenge: over 20% of adolescents globally are believed to grapple with behavioural or mental health issues, with depression emerging as the leading cause of the global disease burden among this demographic. 4udies conducted in India and neighbouring countries highlight the alarming prevalence of depressive disorders among adolescents.For instance, in India, a staggering 40% of adolescents experience depressive disorders, while in Bangladesh, over 80% of college-going adolescents face moderate to severe levels of depression. 5,6Additionally, anxiety disorders affect a significant portion of adolescents, with 3.6% of 10-14-year-olds and 4.6% of 15-19-year-olds experiencing such issues. 7Stress is another factor that poses problems in adolescent life, with up to 61.5% of adolescents affected according to one study.Family conflicts and academic pressures are identified as the main triggers for stress among Indian adolescents. 8,9olescence is a distinct period in human development and crucial for setting the groundwork for long-term health. 4he consequences of untreated mental health conditions among adolescents are severe, ranging from decreased academic performance and attendance to hindered social relationships and reduced employment opportunities. 10,113][14] Depressive disorders are among the top three causes of adolescent DALYs lost globally, and anxiety is among the top five causes of DALYs lost among adolescent girls. 15spite the evident need for intervention, there remains a dearth of research and data on mental health issues among adolescents in specific regions, such as Karnataka.Recognizing this gap, this study aims to estimate the prevalence of depression, anxiety, and stress among adolescents in urban and rural areas of Shivamogga taluk.By gathering more data and understanding the unique challenges faced by adolescents in this region, we can inform targeted interventions and promote positive mental health outcomes among this vulnerable population.

Ethics and consent
Ethical approval was granted by the Institutional Ethics Committee of Shivamogga Institute of medical Sciences, Shivamogga (ref no.SIMS/IEC/414) on 09/11/2018.Informed consent was taken from study participants and the parents/ guardians in case of minors (16-17 years) via Google Forms.Assent was also taken from study participants of age 16-17 years.

Study design and data collection
A cross-sectional study was conducted from August 2020 to September 2020.The study population is composed of all adolescent males and females aged 16-19 years in rural and urban field areas of Shivamogga taluk.

REVISED Amendments from Version 2
The introduction has been comprehensively reviewed and strengthened.
The methodology section has been expanded to provide a more detailed information about assessing DAS.
Potential limitations of the study have been acknowledged in the strengths and limitation section.
Any further responses from the reviewers can be found at the end of the article

Sample size estimation:
Sample size (n) = Z∞ 2 pq/D 2 Z∞ s standard normal deviate at the required confidence level (e.g.Z statistics: 1.96); d is the desired level of precision or level of statistical significance/margin of error the researcher accepts (e.g.0.05); p is estimated characteristics of target population (variability of population parameters) the researcher assumes; and q is 1-p.
According to an Indian study, the prevalence (p) of anxiety among adolescents was found to be 24.4%. 16With desired absolute precision of 5% the minimum sample size required was calculated using the formula Z∞ 2 pq/D 2 .With this, we got a sample size of 295 adolescents.Considering 10% as non-respondents, the final sample size was 325 which was rounded off to 350.So, 350 samples were collected in urban and rural areas each.
The Block education officer was approached and a list of all pre-university colleges in Shivamogga taluk was collected.Shivamogga taluk has 36 pre-university colleges in the urban area and 10 pre-university colleges in the rural area.Then 50% of the pre-university colleges were randomly selected using the random number table both in urban and rural areas.So, 18 colleges from the urban and 5 colleges from the rural area were selected.From each selected colleges, a class was randomly selected.For each selected class the lottery method was used to select 20 students from each class in the urban area and 70 students from the rural area until the desired sample size was reached.All adolescents in the age group of 16 to 19 years were included in the study.Adolescents who did not fill out the questionnaire completely were excluded from the study.
After taking consent, a questionnaire that included basic demographic details (age and sex) with the DASS 21 scale (Depression Anxiety Stress Scale) 17 in the English without any translation or alteration was used to collect data.Given that English is the primary language of instruction at the PU college, we employed the scale without any need for translation.A Google Form of the questionnaire was created, one each for urban and rural areas and the link to fill out the form was shared with students willing to participate in the study via 'WhatsApp' mobile application.Adolescents aged 16 completed years and above until the age of 19 were included in the study.
The Depression, Anxiety, and Stress Scales (DASS) is a set of self-report measures designed to assess the emotional states of depression, anxiety, and stress. 17Each scale provides a score that helps to determine the severity of these emotional states.The interpretation of these scores is based on cutoff values that classify the intensity of the symptoms into different categories: normal, mild, moderate, severe, and extremely severe.
Normal: Scores within this range indicate that the individual is experiencing a typical level of depression, anxiety, or stress, suggesting no significant symptoms in these areas.Depression: 0-9 Anxiety: 0-7 Stress: 0-14 Mild: Scores in this range suggest the presence of mild symptoms.While these might be noticeable, they typically do not cause significant impairment in daily functioning.The DASS consists of 21 items, divided into three self-reported subscales of seven items each, designed to measure depression, anxiety, and stress.Respondents rate each item on a 4-point Likert scale: 0 ("Did not apply to me at all"), 1 ("Applied to me to some extent, or some of the time"), 2 ("Applied to me to a considerable extent, or a good part of the time"), and 3 ("Applied to me very much, or most of the time"), reflecting their feelings over the past week.Each subscale's final score is doubled and assessed according to a severity rating index.The total scores for depression, anxiety, and stress are calculated by summing the values of all items in each of the three subscales, as detailed above.

Statistical analysis
Data was entered into a Microsoft Excel spreadsheet.SPSS (Version 21) was used to perform statistical analysis.Data analysis was done using appropriate statistical tools.Results were expressed in terms of frequency, percentages, Chi-square values, and P-values.All statistical tests were performed with a confidence level of 95% and a power of 80%.In the significance tests, P value equal to or less than 0.05 was considered as statistically significant.

Results
As shown in Table 1: a total of 700 adolescents participated in the study.Out of which 350 (50%) adolescents were from urban areas and another 350 (50%) adolescents were from rural areas.Males and females in urban areas were 153 (44%) and 197 (56%) respectively.In rural areas, males and females were 191 (55%) and 159 (45%) respectively.
Among the adolescents in urban areas, 23.1% were depressed, 29.4% had anxiety and 26.6% had stress.Similarly, among the adolescents in rural areas, 19.1% were depressed, 24% had anxiety and 21.1% were stressed.
Among the depressed adolescents, in urban areas the majority (46; 13.1%) had moderate depression, whereas in rural areas the majority (32; 9.1%) had mild depression.Among the adolescents who had anxiety, both in urban and rural areas the majority (71 (20.3%) and 58 (16.6%) respectively) had moderate anxiety.Among the adolescents who were stressed, both in urban and rural areas, the majority (63 (18%) and 54 (15.4%) respectively) had mild stress.

Discussion
Our study attempted to find out the prevalence of depression, anxiety, and stress among adolescents in urban and rural areas.The current study found that the prevalence of depression was 23.13% and 19.14% in urban and rural areas respectively.On average, depression among adolescents in Shivamogga is 21.14%.Similar results were found by Kumar K S et al. and Sahoo S, where depression among adolescents was 19.5%.and 18.5% respectively. 16,18Depression was seen to be higher in females in both urban and rural areas.The difference was statistically significant in rural areas of Shivamogga.Similar observations were made in other studies across India where depression was seen to be higher among female respondents. 16,19,20Genetic predisposition and hormonal influences could be the reason why depression was higher in females than males.This could also be due to higher reporting of symptoms by females, whereas fewer males may report symptoms due to societal pressure for males to be more emotionally strong.
Depression was more frequently seen in urban adolescents than rural adolescents in the current study (23.1% and 19.4% respectively).Similar observations were made by Bahl R, and Kumari R in their study, where depression among urban adolescents was about 33.3% and depression among rural adolescents was 20.7%. 21This could be due to higher exposure of adolescents to risk factors like academic competition and failure, anxiety, and substance abuse, etc.
Anxiety among adolescents in the current study was found to be 29.2% and 24% in urban and rural areas of Shivamogga respectively.On average, anxiety was found to be 26.6%.This was similar to the study conducted by Kumar K S et al. and Madasu S et al., who found anxiety among adolescents to be 24.4% and 22.7% respectively. 16,22These studies also found that the prevalence of anxiety was higher among females when compared to males.Similar findings were seen in our study in both urban and rural areas.The prevalence of anxiety was significantly higher among females than males in urban areas.Higher anxiety among females could be due to higher exposure to risk factors like academic competition and societal pressure on women to work and prove themselves as equals to males in the modern world.
Anxiety was more frequently seen in urban adolescents than rural adolescents in our study (29.4% and 24% respectively).Similar results were observed by Vs P et al. 23 This could be due to more academic competitiveness in an urban area than in a rural area.While the parental expectation and societal pressure to perform better academically and excel in the future and have a well-paying job is higher for males than females, in the modern world the same pressure is higher in females as well in urban areas.This could be the reason why anxiety was more prevalent among urban females than males.As this study was conducted during the pandemic, the increased awareness of COVID in urban areas with better education could also be the reason why anxiety was higher among urban adolescents.
Stress among the adolescents in our study was found to be 26.6% and 21.1% in urban and rural areas respectively.On average 23.85% of the adolescents were stressed in Shivamogga.Sahoo and Saddicha, in their study, also found that the prevalence of stress among adolescents was 20%. 18Prevalence of stress was found to be higher in urban areas compared to rural areas.Similar observations were made by Dey BK 24 in Bangladesh.No studies from the Indian setting could be found that compared the prevalence of stress in urban and rural areas.
Stress was more frequently seen in males than females in both urban and rural areas of Shivamogga.This was contrary to observations made in other studies, where they found that stress was more prevalent among female participants. 16,24his difference could be due to underreporting of symptoms by female participants.The ongoing pandemic at the time of the study could have contributed to these findings.

Strengths and limitations
The strength of the study lies in its robust methodology, extensive sample size and comprehensive data analysis.This study employed a well-designed survey or assessment tool to gather data, ensuring the accuracy and reliability of the results.The measurement of depression, anxiety, and stress was conducted using a standardized scale rather than through assessment by a trained psychiatrist.
Factors affecting DAS were not investigated in our study.Future research should include an examination of these factors to provide a more comprehensive understanding of DAS.
While we ensured that the collected data is properly segregated into urban and rural categories based on the list of colleges obtained from the block education officer, it is worth noting that some participants from rural areas may commute and study in a college situated in urban areas, and vice versa.

Conclusions
About a quarter of the adolescent population suffers from depression anxiety and stress.It's crucial to detect these symptoms among adolescents and take proper action to avoid compromising their education and development.Those detected to have these symptoms must be referred to be seen by a psychiatrist for clinical evaluation.Further studies are necessary to learn about the causative factors of these mental health disorders.Adopting and implementing better education and health policies are necessary to enhance adolescent mental health.

Rohith Motappa
Department of Community Medicine, Kasturba Medical College, Kasturba Medical College Hospital, Mangalore, Manipal Academy of Higher Education, Karnataka, Manipal, Karnataka, Manipal, 576 104, India This cross-sectional study aimed to assess the extent of depression, anxiety, and stress among adolescents residing in urban and rural areas of Shivamogga Taluk.Data was gathered over August and September 2020 through surveys involving 700 teens aged 16 to 19.
The results showed that these mental health issues were common in both urban and rural adolescents, with higher rates observed in urban areas.Females consistently showed rates across all mental health conditions.
The author should consider expanding on the following areas: 1.If a selected student was absent during the data collection, how was the situation handled to maintain the desired sample size?What specific steps were taken in such cases?2. The author may include the implications of this study in the discussion.
3. The author may also include some additional limitations of the study.

Are sufficient details of methods and analysis provided to allow replication by others? Partly
If applicable, is the statistical analysis and its interpretation appropriate?Yes Are all the source data underlying the results available to ensure full reproducibility?Yes

Are the conclusions drawn adequately supported by the results? Partly
Competing Interests: No competing interests were disclosed.
I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard.
1.This was a very simple study where the authors just assessed DAS among 350 adolescents.
There is a major limitation of demographic variables in this study.There are many factors that affects DAS of adolescents.
2. The study just presented frequency distribution, and no inferential statistics has presented.
3. The abstract of the study is insufficient and lack of key information.In abstract, the authors reported their study objectives in methods section.But, it should be place at the end of Background/Introduction section.In the methods section, the authors should report about DAS 21 and its' computational ways, and appropriate statistical analysis.There are many factors that affects DAS of adolescents.

○
Author's Response: The study was conducted on 700 adolescents with 350 adolescents in urban and rural areas respectively.The sample size estimation for this study is clearly mentioned in the methodology and the number was not chosen arbitrarily.We have already agreed that measurement of depression, anxiety and stress among adolescents with a standard scale and not by a trained psychiatrist is a limitation of the study.Study of factors that affect DAS among adolescents was not in the scope of this study.This may be incorporated into future studies.

Comment:
The study just presented frequency distribution, and no inferential statistics has presented.

○
Author's Response: We believe that presenting the frequency distribution serves as a critical first step in understanding the scope of these mental health issues in the region.It offers a clear and immediate representation of the data, which is particularly valuable for an area that has been under-researched in this context.While we acknowledge the value of inferential statistics in drawing broader conclusions from the data, the primary aim of our study was to highlight the prevalence rates and lay the groundwork for future research that may include more sophisticated statistical analyses.In future studies, we plan to incorporate inferential statistics to explore the relationships between various demographic

Indranil Saha
ICMR-Centre for Ageing and Mental Health (I-CAM), Indian Council of Medical Research, Kolkata, West Bengal, India The manuscript needs following clarifications: "p-values less than 0.05 were considered significant" -please correct as p value equal to or less than 0.05 was considered as statistically significant 1.
As per rule the adolescents with completed 19 years should have been included as study participants 2.
Colleges situated in urban and rural area: whether urban college truly represent urban adolescents?There may be so may students from rural area studying in urban college and the vice versa may be true.

3.
How socioeconomic status was measured in both the colleges?4.
In which language this DASS 21 scale was used?Was it validated and reliable in that settings?6.

If applicable, is the statistical analysis and its interpretation appropriate? Yes
Are all the source data underlying the results available to ensure full reproducibility?Yes

Are the conclusions drawn adequately supported by the results? Yes
Competing Interests: No competing interests were disclosed.
Reviewer Expertise: Epidemiology, Non-communicable disease, Mental health I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard, however I have significant reservations, as outlined above.included as study participants Author's Response: We agree with your comment.We would like to clarify that adolescents who have completed 19 years were included in the study.Action Taken in the manuscript: we have mentioned that adolescents aged 19 years have included in the study in the methodology section.
Comment: Colleges situated in urban and rural area: whether urban college truly represent urban adolescents?There may be so may students from rural area studying in urban college and the vice versa may be true.

○
Author's Response: In the data collection process, we ensured that the collected data is properly segregated into urban and rural categories based on the list of colleges obtained from the block education officer.However, we acknowledge that some participants may commute and study in a college that does not accurately represent the demography (urban and rural).This can be seen as a limitation of the study.Action Taken in the manuscript: Necessary changes have been done in the strengths and limitation section.
Comment: How socioeconomic status was measured in both the colleges?○ Author's Response: We have not measured the socioeconomic status of the participants in the study.Action Taken in the manuscript: As socioeconomic status was not included in the original study instrument we have not included it in the study.
Comment: Please edit the sample size formula -"n=4pq/D2" instead of 4, please mention as Z∞ 2 ○ Author's Response: We agree with your observation.Action Taken in the manuscript: Necessary changes have been done in the manuscript.
Comment: In which language this DASS 21 scale was used?Was it validated and reliable in that settings?○ Author's Response: DASS21 Scale was used in English in our study without any translation or alteration.As the students studying in PU college have English as their first language we used the scale without any translations.DASS21 scale in English is already validated among adolescents.Action Taken in the manuscript: We have duly incorporated this information into the methodology section of the manuscript for clarity.
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Table 1 .
Distribution of study participants according to depression, anxiety and stressed in urban and rural areas.(n=700).

Table 2 .
Distribution of study participants based on sex in urban areas of Shivamogga (n=350).

Table 3 .
Distribution of study participants based on sex in rural areas of Shivamogga (n=350).

have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard, however I have significant reservations, as outlined above. Version 2
No competing interests were disclosed.
https://doi.org/10.5256/f1000research.164841.r287888©2024 Rajamanickam S. This is an open access peer review report distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.Saranya Rajamanickam PSG Institute of Medical Sciences & Research, Coimbatore, Tamil Nadu, India Methodology:1.Operational definition of dependent variable such as depression, stress and anxiety can be mentioned.2. Type of sampling can be mentioned.3. Need for separate google forms for urban and rural area can be explained.4. Scoring of depression, anxiety and stress to categorize it into mild, moderate an severe is not clear.Result: 5. A table depicting the frequency of depression, anxiety and stress among the urban and rural area explaining the objective will be appreciated.6. Significant p value can be highlighted in all the tables and the level of confidence interval can be written below each table.Competing Interests: Nil Close

Is the work clearly and accurately presented and does it cite the current literature? Yes Is the study design appropriate and is the work technically sound? Yes Are sufficient details of methods and analysis provided to allow replication by others? Partly If applicable, is the statistical analysis and its interpretation appropriate? Yes Are all the source data underlying the results available to ensure full reproducibility? Yes Are the conclusions drawn adequately supported by the results? Yes Competing Interests:
No competing interests were disclosed.

have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard, however I have significant reservations, as outlined above.
Reviewer Report 24 June 2024 https://doi.org/10.5256/f1000research.164841.r287883© 2024 Motappa R.This is an open access peer review report distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

is the statistical analysis and its interpretation appropriate? Partly Are all the source data underlying the results available to ensure full reproducibility? Partly Are the conclusions drawn adequately supported by the results? Partly Competing Interests:
4. The results section in abstract is incomplete.The author should report associated factors of DAS among adolescents.5.In the main text, the writings of introduction is very poor.The author are requested to add the recent literature and statistics in the introduction, avoiding orphan paragraphs.The introduction would be sound if the author would report the DAS of adolescents in the similar sociodemographics in South-Asia.[Ref.: Siddik M, et al., 2024 [Ref-1]; Mridha MK et al., 2021 [Ref-2]; Singh MM, et al., 2017 [Ref-3]; Bhattarai D, et al., 2020 [Ref-4]] 6.The methods of the study is very poor.The sample size estimation formula should write appropriately.The should report the scaling and scoring techniques of DAS 21. 7. To enrich the Methods of the study, the authors are requested to follow any standard approach of writing Methods [e.g,.Haque M, et al., 2023 [Ref-5]; Siddik M, et al., 2024 [Ref-1]].8.In the results section, the authors are strongly recommended to add inferential statistics to identify the associated risk factors of DAS among adolescents.9.The discussion should be revised according to the new results.No competing interests were disclosed.

have read this submission and believe that I have an appropriate level of expertise to state that I do not consider it to be of an acceptable scientific standard, for reasons outlined above.
This was a very simple study where the authors just assessed DAS among 350 adolescents.There is a major limitation of demographic variables in this study.